Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oswego Operator, Llc during CMS and state inspections, most recent first.
Kitchen sanitation, food temperature control, and food handling practices were deficient. Surveyors observed missing floor tiles, flaking ceiling paint, flies, open and undated food items, and expired spices in the pantry. Staff did not consistently record temps for hot holding, pureed, or mechanical soft foods, and one meal was served with items at 50, 40, and 80 degrees. Surveyors also observed a dietary employee cough into her shirt and continue food prep without hand hygiene or glove change, and another use a prep knife to open condiment wrap before returning to chicken prep. A resident received a cold cheeseburger without temp verification, and residents reported hot food was often served cold.
Loose Handrails in Resident Hallways: Surveyors found loose handrails in three of four resident hallways, including multiple loose handrails in the north, east, and south halls. Staff interviews confirmed that all employees were responsible for identifying and reporting maintenance issues, but Maintenance stated no work orders had been received for the loose handrails. The facility policy required maintenance work orders to be completed to establish priority of service.
Failure to provide transfer notifications and bed-hold documentation: The facility did not give written transfer notices to three residents or send copies to the ombudsman, and one resident also lacked a signed bed hold. One resident with ESRD and cognitive deficits was hospitalized after an allergic reaction to antibiotics post-op, another with hydronephrosis and acute kidney failure was sent out for surgery, and a third with CHF was transferred for cough, low O2 sat, weakness, and inability to swallow. Staff stated they were unaware of the written notice and ombudsman notification requirements.
A resident with edema, AFib, hypothyroidism, and some to moderate cognitive impairment had an order and care plan for TED hose/compression stockings to be worn in the morning and removed at bedtime. Staff documented the stockings as applied and removed on the MAR/TAR even when observations showed the resident was not wearing them and her feet and ankles were swollen. Interviews confirmed staff did not verify the treatment before charting it and that refusals should have been documented if the resident did not wear the stockings.
Inaccurate PBJ Staffing Submission: The facility failed to submit complete and accurate PBJ staffing data for weekend nursing coverage. Although payroll and scheduling data reflected similar weekend coverage to other days, the PBJ report showed excessively low weekend staffing because all RNs except the DON were reported under the same category, causing administrative nurses to be counted with floor nursing staff.
The facility failed to submit accurate staffing data to CMS, as their PBJ reports did not reflect actual RN and licensed nurse coverage due to the removal of 30-minute meal breaks. Despite having 24/7 licensed nursing staff and consistent weekend staffing, the facility's reports inaccurately documented a lack of coverage on multiple dates. The facility lacked a policy to ensure accurate PBJ reporting.
The facility failed to maintain sanitary practices in ice distribution, glucometer sanitization, and medication administration. Housekeeping staff used an uncovered container for ice, a nurse used inappropriate wipes for glucometers, and a medication aide prepared medications without proper hand hygiene. These actions were confirmed by staff interviews and observations.
A facility failed to follow physician's orders for a resident on anti-hypertensive medication by not obtaining blood pressure readings before administering amlodipine. The resident's care plan required withholding the medication if certain blood pressure parameters were not met, but staff did not adhere to this protocol from December to May, leading to a deficiency.
A facility failed to ensure a licensed pharmacist identified staff's failure to obtain blood pressures for a resident before administering anti-hypertensive medication, as ordered. The resident had hypertension and severely impaired cognition, with a care plan requiring blood pressure checks before medication. Staff did not obtain readings from December 2023 to May 2024, and the medication was given outside parameters once. The facility lacked a policy on pharmacy consultant responsibilities.
A resident with a history of diabetes and heart failure experienced a urinary tract infection. Despite a culture report showing resistance to ciprofloxacin, the resident was administered this ineffective antibiotic. The infection persisted until ceftriaxone, a sensitive antibiotic, was prescribed. The facility's failure to follow its Antibiotic Stewardship Program led to this deficiency.
Food Storage, Temperature Monitoring, and Cross-Contamination Failures
Penalty
Summary
Sanitary conditions in the kitchen and food storage areas were not maintained. During the initial tour, surveyors observed missing floor tiles at the kitchen entry, flaking paint on multiple ceiling areas including above the handwashing sink, three flies in the kitchen, an open tub of butter beside an open bag of biscuits, and food waste on the floor. In the pantry, an opened package of spaghetti had no date, flour was scattered on a container, floor, shelves, and a transport cart, and the spice drawer contained 16 open spice containers that were not dated. Several spices were expired, including smoked paprika, thyme, and pumpkin spice. Dietary staff stated that cooks were responsible for dating opened items and discarding expired items, and that the night cook had gone through the spice drawer the prior night. Food preparation and holding practices were also inconsistent with required temperature monitoring. Surveyors observed heating table temperatures were not checked or recorded while foods were being held for residents, and no food temperatures were checked before service. The rice was temperature checked before being pureed, but not after preparation, and no temperature was documented for meals served on multiple days. The temperature logs showed no recorded temperatures for mechanical soft or pureed meals on several dates, and one supper meal had a main entree at 50 degrees, vegetables at 40 degrees, and dessert at 80 degrees. Staff interviews confirmed that pureed and mechanical soft foods should have been temperature checked after preparation and before serving, and that cold items such as tuna salad should not be served above 41 degrees. Unsafe food handling was directly observed during meal preparation and service. One dietary employee chopped lettuce, coughed into her shirt while holding it with a gloved hand, and then returned to chopping without hand hygiene or changing gloves. The same employee used a knife that had been used on chicken to open plastic wrap on a barbeque sauce bottle and then resumed chopping chicken without washing or changing knives. Another dietary employee delivered a cheeseburger to a resident without checking its temperature, and the resident and spouse reported that it was cold. Residents also reported that hot food was often not hot and meats were often cold when served. Staff interviews confirmed expectations for hand hygiene after coughing, changing gloves, and avoiding cross-contamination with utensils used for food preparation.
Loose Handrails in Resident Hallways
Penalty
Summary
Firmly secured handrails were not provided on each side of the hallways, and the facility failed to provide safe and functional handrails in three of four hallways for a census of 29 residents. Survey observations identified four loose handrails in the north resident hall, five loose handrails in the east resident hall, and three loose handrails in the south resident hall. During a later observation, administrative staff were checking handrails throughout the building and marking loose handrails so residents and staff could safely identify them. Interviews with Administrative Nurse D, Dietary GG, Maintenance U, and Administrative Staff A confirmed that all staff were responsible for identifying and reporting maintenance issues, that work orders could be submitted by any employee, and that regular rounds were performed with an environmental checklist. Maintenance U stated handrails were checked every three to four months and while walking down the hall, and also stated she had not received any work orders identifying loose handrails. The facility policy Work Orders, Maintenance, dated 10/2025, stated that maintenance work orders should be completed to establish a priority of maintenance service.
Failure to Provide Transfer Notifications and Bed-Hold Documentation
Penalty
Summary
The facility failed to provide written notification of transfer to the resident and/or the resident’s representative as soon as practicable for three residents, and failed to send a copy of that notification to the ombudsman. Resident 4 had diagnoses including end-stage renal disease, cognitive communication deficit, and dependence on dialysis. Nursing documentation showed the resident was prepared for a procedure on 08/20/25 and was admitted to the hospital on 08/21/25 for observation after an allergic reaction to antibiotics given after surgery, but the electronic record lacked documentation of a signed bed hold or a written transfer notification explaining the reason for the hospital transfer. Resident 9 had hydronephrosis with renal and ureteral calculous obstruction and acute kidney failure, and was transported to the hospital for a surgical procedure; although the bed hold was signed, the record lacked documentation of a written notification to the resident and/or representative explaining the reason for transfer. Resident 32 had congestive heart failure and was transported to the hospital for a cough, oxygen saturation of 85%, weakness, and inability to swallow, but the electronic record also lacked documentation of written notification to the resident and/or representative explaining the reason for the transfer. Staff interviews indicated the social services staff member was unaware of the regulation to notify the resident in writing and notify the ombudsman of transfers, and administrative staff confirmed the facility had not been notifying the ombudsman.
Inaccurate Documentation of Compression Stocking Use
Penalty
Summary
The facility failed to ensure nursing documentation in Resident 10’s health record met professional standards of care when staff repeatedly documented compression stockings as applied and removed even when they were not actually on the resident. Resident 10 had diagnoses including rhabdomyolysis, atrial fibrillation, hypothyroidism, and edema, and the MDS documented some to moderate cognitive impairment along with assistance needs for dressing and footwear. The care plan and physician order directed that compression hose be worn in the morning and removed at bedtime for lower extremity swelling. Review of the December 2025 MAR/TAR showed no documentation for compression stockings on 12/25/25, but on 12/28/25 they were charted as applied at 06:00 AM and removed at 07:00 PM, and on 12/29/25 they were charted as on at 06:00 AM. However, observations on 12/28/25 and 12/29/25 showed Resident 10’s feet and ankles were swollen and she was not wearing compression stockings. During interviews, a CNA stated staff were expected to verify treatments were performed and report refusals, while an LN stated CNAs put the stockings on and the nurse verified it before charting, but she admitted she assumed the resident had put them on and had not confirmed it before documenting them as on. An Administrative Nurse stated staff were expected to verify treatments before charting them as completed and to document refusals when applicable. The facility policy stated services provided to the resident or changes in condition should be documented in the medical record.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS through Payroll-Based Journal (PBJ) when it did not accurately submit hourly staffing data for all nursing personnel for weekends. The facility reported a census of 29 residents. Review of the PBJ Staffing Data Report for FY Quarter 3 - 2025 (April 1 - June 30) showed excessively low weekend staffing. During interview, Administrative Staff A stated that payroll data and scheduling data reflected the facility had the same coverage on weekends, if not more than on other days. Consultant II stated that all RNs except the DON were reported under the same category, so administrative nurses who worked during the week were counted in the same category as licensed nurses who worked on the floor, which made weekend staffing appear lower when administrative staff were not working. The facility also provided the CMS Electronic Staffing Data Submission PBJ LTC Facility Policy Manual, version 2.7, dated June 2025, which stated that direct care staffing and census data are collected quarterly and are required to be timely and accurate.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) as required. Specifically, the facility's Payroll Base Journal (PBJ) Staffing Data Report for the second and third quarters of fiscal year 2023 documented a lack of licensed nursing coverage for 24 hours a day on multiple dates. However, a review of the facility's time sheets and staff postings revealed that the facility did have RN coverage for eight consecutive hours each day and 24/7 licensed nursing staff coverage, including consistent weekend staffing. The discrepancy arose because the facility's PBJ reports did not accurately reflect the actual staffing coverage due to the removal of 30-minute meal breaks when licensed nurses and RNs remained on site. Administrative Staff A and Administrative Staff B confirmed that the facility's PBJ reporting to CMS was inaccurate and did not reflect the direct care provided by administrative nursing staff and licensed nurses. The facility lacked a policy to ensure the submission of accurate PBJ staffing reports to CMS, which contributed to the inaccurate data submission. The report highlights the facility's failure to comply with CMS requirements for reporting staffing information, which is based on payroll and other verifiable and auditable data.
Infection Control Deficiencies in Ice Distribution, Glucometer Sanitization, and Medication Administration
Penalty
Summary
The facility failed to ensure sanitary practices in three key areas, leading to potential infection risks among residents. Firstly, housekeeping staff distributed ice to residents using a large, uncovered container with the scoop stored directly in the ice, contrary to the facility's policy requiring ice to be covered and the scoop kept separate to prevent contamination. This was confirmed by both the housekeeping staff and administrative staff during interviews. Secondly, a licensed nurse used inappropriate sanitizing wipes on glucometers, which did not list hepatitis as susceptible to the chemicals in the wipe. The nurse admitted to using a non-medical grade wipe due to a shortage of the appropriate sanitizing wipes, as confirmed by administrative staff. Lastly, a certified medication aide prepared medications without sanitizing hands or wearing gloves, and used a paper clip to open a gel tab, which was not in line with the facility's hand hygiene policy. These actions were observed and confirmed by administrative staff, highlighting a failure to maintain sanitary conditions during medication administration.
Failure to Monitor Blood Pressure Before Administering Medication
Penalty
Summary
The facility failed to adhere to physician's orders for a resident diagnosed with hypertension, who was on anti-hypertensive medication. The resident's care plan specified that amlodipine, a medication used to lower blood pressure, should be withheld if the systolic blood pressure (SBP) was less than 110, the diastolic blood pressure (DBP) was less than 40, or if the pulse was less than 40 beats per minute. However, from December 12, 2023, to May 7, 2024, the staff did not obtain the resident's blood pressure before administering the medication, as required by the physician's order. Additionally, on one occasion between May 8, 2024, and May 20, 2024, the medication was administered when the resident's blood pressure was outside the specified parameters. The deficiency was confirmed through interviews and record reviews. A licensed nurse acknowledged that blood pressures were not taken before administering amlodipine, and an administrative nurse indicated she would investigate the issue. The facility's policy, effective April 2023, required nursing staff to assess and document vital signs as needed, but this protocol was not followed in the case of this dependent resident. The failure to monitor the resident's blood pressure before administering the anti-hypertensive medication led to the deficiency identified in the report.
Failure to Monitor Blood Pressure Before Administering Medication
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review and identified the staff's failure to obtain blood pressures for Resident 20 before administering anti-hypertensive medication, as ordered. Resident 20 had a diagnosis of hypertension and severely impaired cognition. The care plan required staff to hold the medication if the resident's systolic blood pressure was less than 110, diastolic blood pressure was less than 40, or pulse was less than 40 beats per minute. However, from December 12, 2023, to May 7, 2024, staff did not obtain blood pressure readings before administering the medication, and on one occasion, the medication was administered when the resident's blood pressure was outside the specified parameters. The deficiency was confirmed through observation, interview, and record review. On May 20, 2024, a licensed nurse confirmed that staff had not obtained blood pressures before administering amlodipine. An administrative nurse acknowledged the issue and stated she was responsible for monitoring pharmacy consultant recommendations. The facility lacked a policy regarding pharmacy consultant responsibilities, and the pharmacist was unavailable for an interview. This oversight in monitoring the resident's blood pressure before medication administration led to the deficiency.
Failure in Antibiotic Stewardship for UTI Treatment
Penalty
Summary
The facility failed to ensure proper antibiotic stewardship for a resident with a urinary tract infection. The resident, who had a history of diabetes, congestive heart failure, and anxiety, was assessed with normal cognitive function and required partial to moderate assistance for activities of daily living. The resident reported symptoms of a urinary tract infection, prompting the physician to order a urinalysis, culture, and sensitivity test. The culture report indicated the presence of Escherichia coli resistant to ciprofloxacin, yet the physician instructed the administration of ciprofloxacin, which was ineffective against the bacteria. The resident received ciprofloxacin for seven days, but a subsequent culture report confirmed the persistence of the infection, showing sensitivity to ceftriaxone. The physician then prescribed ceftriaxone, which was effective in treating the infection. Interviews with nursing staff revealed an expectation to review culture reports and inform the physician of any resistance, which was not done in this case. The facility's policy required an Antibiotic Stewardship Program with protocols and monitoring, which was not effectively implemented, leading to the administration of an ineffective antibiotic for the resident's condition.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oswego
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medicalodges Columbus | 14.1 mi | ★★★★★ | 1 | 1 |
| Elmhaven East | 14.1 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Parsons | 14.8 mi | ★★★★★ | 0 | 0 |
| Parsons Presbyterian Manor | 16.1 mi | ★★★★★ | 4 | 0 |
| Eastwood Manor | 20.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.